The anterior approach to hip arthroscopy (replacement) is an innovative alternative to traditional hip replacement in which the incision to access the joint is made on the front of the leg rather than the back or side of the leg.
By using this approach, surgeons are able to access the hip joint by gently spreading the muscles, leaving them relatively undisturbed whereas. In a traditional joint replacement, these muscles would be cut in order to access the joint.
In this segment, Dr. Jacob Gunzenhaeuser discusses anterior hip replacement and when to refer to a specialist.
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Anterior Hip Replacement
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Learn more about Jacob Gunzenhaeuser, MD
Jacob Gunzenhaeuser, MD
Jacob M. Gunzenhaeuser, MD, joined The Christ Hospital Orthopaedics & Sports Medicine practice in August 2016. Dr. Gunzenhaeuser earned his medical degree from The University of Cincinnati College of Medicine, completed his residency at the University of Cincinnati Department of Orthopaedic Surgery, and completed his sports medicine fellowship at Campbell Clinic Orthopaedics - University of Tennessee.Learn more about Jacob Gunzenhaeuser, MD
Transcription:
Anterior Hip Replacement
Melanie Cole (Host): The anterior hip replacement is a newer technique that has the same results as traditional hip replacements procedure, but has more benefits for the patient. The difference in the two techniques is how the surgeon opens the body to reach the hip joint. My guest today is Dr. Jacob Gunzenhaeuser. He's an orthopedic surgeon with the Christ Hospital Health Network. Dr. Gunzenhaeuser, welcome to the show. Explain a little bit about how hip replacement has been done in the past, and what's prompted this newer type of technique.
Dr. Jacob Gunzenhaeuser, MD (Guest): Thank you Melanie; thanks for having me. So, traditionally, hip replacement has been done through a posterior approach, basically coming through the gluteal region, getting into the joint. This has been an extensile approach. It can be extended proximally and distally so that you can do a lot of work that way. The push for the anterior approach has been pretty much over the past 20 years brought by Joel Matta out of California basically to minimize the trauma to the muscles to the hip, encouraging a faster recovery as well as decreased risk of hip dislocation and also allows us to use an X-ray machine intraoperatively to confirm appropriate hip implant positioning before we leave the operating room.
Melanie: And Doctor...what do you tell patients about when is the time for them to consider looking into hip replacement in the first place -- as far as hip degeneration. How do you speak to them about that next step?
Dr. Gunzenhaeuser: Well, typically we start with non-operative treatment starting with anti-inflammatory medication, physical therapy, working on strengthening of the muscles around the hip as well as keeping their motion and potentially cortisone injections into the hip can be tried before even discussing surgery. When the time comes for surgery, it really is the patient's decision. They will kind of -- they usually know when it's time. It's when they're not sleeping at night. They can't do the things they like to do during the day. They can't work, you know, that kind of stuff. They really kind of know when it's time.
Melanie: So, then once you've made the decision with the patient, what about patient selection criteria? Are there certain candidates for whom this is not an option?
Dr. Gunzenhaeuser: When the anterior approach was first being established, the ideal candidate was a skinny patient, not too muscular. It made the approach much easier, but as people become more familiar with the approach, essentially anyone that is a candidate for a hip replacement through the standard posterior approach can also be done through an anterior approach. That includes even very muscular people, and it really depends on the experience and the familiarity with the surgeon with the approach. But yeah, anyone that can do the standard posterior approach can also do an anterior approach. It goes for primary hip arthroplasty. There's a few select situations in redo surgeries or revision surgeries where a posterior approach would be required.
Melanie: So then speak about the procedure itself, and what would be involved as far as positioning and all of those kinds of factors.
Dr. Gunzenhaeuser: So, with the anterior approach as opposed to the standard posterior approach, the patient can lay supine, meaning on their back on the operating room table. This gives a couple of benefits of being able to use an X-ray machine again to confirm the implant positioning. This can be done on a regular OR table, but here at The Christ Hospital, we use a special Hana table which allows us to extend the hip and move the femur into a position where we can put the implant in. This allows us to make smaller incisions as well as use a natural intermuscular approach so that we don't have to actually cut any muscle. We just kind of spread through the muscle and intermuscular plane getting into the hip joint.
Melanie: Are you using MAKOplasty for this hip replacement?
Dr. Gunzenhaeuser: I have trained on the MAKOplasty, and I think it has its place, but with the anterior hip approach, I don't think it's necessary. The reason is we have the X-ray machine which can confirm our implant positioning. The MAKOplasty -- in my opinion may be an added expense which is not needed as well as it requires a couple of larger incisions in order to get the tracking devices into the bone, and you also have to get a CT scan prior to surgery, which to me is unnecessary radiation.
Melanie: Are there any disadvantages to the anterior approach?
Dr. Gunzenhaeuser: In my opinion, not really. Not for a primary total hip replacement. A few things that we know is with the surgeon that's just starting to use the approach, the complication rate may be slightly higher. It is a slightly steep learning curve so there's been with the newer physicians doing the approach, a few higher risks of fractures of the bone as well as a nerve palsy. It's your lateral femoral cutaneous nerve which is just a skin nerve to the lateral thigh, so a lot of patients will feel some numbness over the upper lateral side following surgery. This typically improves with time, but some patients have some permanent mild numbness which they don't even recognize usually after six months to a year.
Melanie: And you mentioned that it's a learning curve for this procedure, and what do you think that curve is? I mean, in your opinion, doctor, what would you think would make somebody more technically savvy for this type of procedure?
Dr. Gunzenhaeuser: Well, I think most of the newer surgeons coming out training have done this in residency, and so they're familiar with it. A lot of the older surgeons that have been trained with the posterior approach, it takes a little bit of a learning curve to kind of switch over, and I think that's why in a lot of areas, you'll actually find the posterior approach still being done more commonly. And actually our long-term studies show that the overall outcomes in the long term are very, very similar, really not much of a difference. It's more the early recovery which is the benefit of the anterior approach as well as the slightly decreased risk of dislocation.
Melanie: What about for very obese people and wound healing issues -- is there a connection there? Do you see that this could sometimes be an issue?
Dr. Gunzenhaeuser: Absolutely, it can be an issue. If the abdominal pannus is over the incision, it leads to a very moist environment, and it can lead to skin breakdown over the incision and potentially even infection. So, we have a team here that kind of teaches the patient especially about keeping the area dry and on these patients where the pannus actually folds over the incision, we use a wound vacuum -- it's an incisional vacuum that goes over the incision, keeps it completely dry and actually kind of sucks off some of the moisture that may come out of the wound, and we leave that on for about 10 days to two weeks, and the patient can go home with that and the machine just shuts off when it's time, and at that point, the skin is mostly sealed over, but absolutely, that's one of the bigger problems with the obese patients.
Melanie: In summary, Doctor, tell other physicians what you'd like them to know about anterior hip replacement and the procedure itself and when to refer to a specialist.
Dr. Gunzenhaeuser: Well, I’d think I’d like people to know the anterior approach is really something that's been proven over the past 20 years. It has good studies to support it. It is as successful, if not better than the posterior approach as far as its long-term studies. It provides early, rapid recovery, a decreased dislocation risk as well as a way for us to confirm the implants are placed appropriately before we leave the OR. At this point, experienced surgeons in the anterior approach can do any patient that they would normally do through a standard posterior approach. That's no longer a concern as well as we're able to do many revisions through an anterior approach. Anytime there's a concern for hip pain, I think, we in the orthopedic field are happy to see people, even if it's not a patient that is ready for surgery at least so we can educate them on what they can be doing as far as losing weight, exercising in order to maintain their hip as long as they can, and also ways to help treat the pain until it really becomes no longer manageable, and they have to discuss surgery.
Melanie: Thank you so much, Dr. Gunzenhaeuser for being with us today. You're listening to Expert Insights Physician Views and News with The Christ Hospital Health Network. For more information on Dr. Gunzenhaeuser and all of The Christ Hospital physicians, you can go to tchpconnect.org. That's tchpconnect.org. This is Melanie Cole. Thanks so much for listening.
Anterior Hip Replacement
Melanie Cole (Host): The anterior hip replacement is a newer technique that has the same results as traditional hip replacements procedure, but has more benefits for the patient. The difference in the two techniques is how the surgeon opens the body to reach the hip joint. My guest today is Dr. Jacob Gunzenhaeuser. He's an orthopedic surgeon with the Christ Hospital Health Network. Dr. Gunzenhaeuser, welcome to the show. Explain a little bit about how hip replacement has been done in the past, and what's prompted this newer type of technique.
Dr. Jacob Gunzenhaeuser, MD (Guest): Thank you Melanie; thanks for having me. So, traditionally, hip replacement has been done through a posterior approach, basically coming through the gluteal region, getting into the joint. This has been an extensile approach. It can be extended proximally and distally so that you can do a lot of work that way. The push for the anterior approach has been pretty much over the past 20 years brought by Joel Matta out of California basically to minimize the trauma to the muscles to the hip, encouraging a faster recovery as well as decreased risk of hip dislocation and also allows us to use an X-ray machine intraoperatively to confirm appropriate hip implant positioning before we leave the operating room.
Melanie: And Doctor...what do you tell patients about when is the time for them to consider looking into hip replacement in the first place -- as far as hip degeneration. How do you speak to them about that next step?
Dr. Gunzenhaeuser: Well, typically we start with non-operative treatment starting with anti-inflammatory medication, physical therapy, working on strengthening of the muscles around the hip as well as keeping their motion and potentially cortisone injections into the hip can be tried before even discussing surgery. When the time comes for surgery, it really is the patient's decision. They will kind of -- they usually know when it's time. It's when they're not sleeping at night. They can't do the things they like to do during the day. They can't work, you know, that kind of stuff. They really kind of know when it's time.
Melanie: So, then once you've made the decision with the patient, what about patient selection criteria? Are there certain candidates for whom this is not an option?
Dr. Gunzenhaeuser: When the anterior approach was first being established, the ideal candidate was a skinny patient, not too muscular. It made the approach much easier, but as people become more familiar with the approach, essentially anyone that is a candidate for a hip replacement through the standard posterior approach can also be done through an anterior approach. That includes even very muscular people, and it really depends on the experience and the familiarity with the surgeon with the approach. But yeah, anyone that can do the standard posterior approach can also do an anterior approach. It goes for primary hip arthroplasty. There's a few select situations in redo surgeries or revision surgeries where a posterior approach would be required.
Melanie: So then speak about the procedure itself, and what would be involved as far as positioning and all of those kinds of factors.
Dr. Gunzenhaeuser: So, with the anterior approach as opposed to the standard posterior approach, the patient can lay supine, meaning on their back on the operating room table. This gives a couple of benefits of being able to use an X-ray machine again to confirm the implant positioning. This can be done on a regular OR table, but here at The Christ Hospital, we use a special Hana table which allows us to extend the hip and move the femur into a position where we can put the implant in. This allows us to make smaller incisions as well as use a natural intermuscular approach so that we don't have to actually cut any muscle. We just kind of spread through the muscle and intermuscular plane getting into the hip joint.
Melanie: Are you using MAKOplasty for this hip replacement?
Dr. Gunzenhaeuser: I have trained on the MAKOplasty, and I think it has its place, but with the anterior hip approach, I don't think it's necessary. The reason is we have the X-ray machine which can confirm our implant positioning. The MAKOplasty -- in my opinion may be an added expense which is not needed as well as it requires a couple of larger incisions in order to get the tracking devices into the bone, and you also have to get a CT scan prior to surgery, which to me is unnecessary radiation.
Melanie: Are there any disadvantages to the anterior approach?
Dr. Gunzenhaeuser: In my opinion, not really. Not for a primary total hip replacement. A few things that we know is with the surgeon that's just starting to use the approach, the complication rate may be slightly higher. It is a slightly steep learning curve so there's been with the newer physicians doing the approach, a few higher risks of fractures of the bone as well as a nerve palsy. It's your lateral femoral cutaneous nerve which is just a skin nerve to the lateral thigh, so a lot of patients will feel some numbness over the upper lateral side following surgery. This typically improves with time, but some patients have some permanent mild numbness which they don't even recognize usually after six months to a year.
Melanie: And you mentioned that it's a learning curve for this procedure, and what do you think that curve is? I mean, in your opinion, doctor, what would you think would make somebody more technically savvy for this type of procedure?
Dr. Gunzenhaeuser: Well, I think most of the newer surgeons coming out training have done this in residency, and so they're familiar with it. A lot of the older surgeons that have been trained with the posterior approach, it takes a little bit of a learning curve to kind of switch over, and I think that's why in a lot of areas, you'll actually find the posterior approach still being done more commonly. And actually our long-term studies show that the overall outcomes in the long term are very, very similar, really not much of a difference. It's more the early recovery which is the benefit of the anterior approach as well as the slightly decreased risk of dislocation.
Melanie: What about for very obese people and wound healing issues -- is there a connection there? Do you see that this could sometimes be an issue?
Dr. Gunzenhaeuser: Absolutely, it can be an issue. If the abdominal pannus is over the incision, it leads to a very moist environment, and it can lead to skin breakdown over the incision and potentially even infection. So, we have a team here that kind of teaches the patient especially about keeping the area dry and on these patients where the pannus actually folds over the incision, we use a wound vacuum -- it's an incisional vacuum that goes over the incision, keeps it completely dry and actually kind of sucks off some of the moisture that may come out of the wound, and we leave that on for about 10 days to two weeks, and the patient can go home with that and the machine just shuts off when it's time, and at that point, the skin is mostly sealed over, but absolutely, that's one of the bigger problems with the obese patients.
Melanie: In summary, Doctor, tell other physicians what you'd like them to know about anterior hip replacement and the procedure itself and when to refer to a specialist.
Dr. Gunzenhaeuser: Well, I’d think I’d like people to know the anterior approach is really something that's been proven over the past 20 years. It has good studies to support it. It is as successful, if not better than the posterior approach as far as its long-term studies. It provides early, rapid recovery, a decreased dislocation risk as well as a way for us to confirm the implants are placed appropriately before we leave the OR. At this point, experienced surgeons in the anterior approach can do any patient that they would normally do through a standard posterior approach. That's no longer a concern as well as we're able to do many revisions through an anterior approach. Anytime there's a concern for hip pain, I think, we in the orthopedic field are happy to see people, even if it's not a patient that is ready for surgery at least so we can educate them on what they can be doing as far as losing weight, exercising in order to maintain their hip as long as they can, and also ways to help treat the pain until it really becomes no longer manageable, and they have to discuss surgery.
Melanie: Thank you so much, Dr. Gunzenhaeuser for being with us today. You're listening to Expert Insights Physician Views and News with The Christ Hospital Health Network. For more information on Dr. Gunzenhaeuser and all of The Christ Hospital physicians, you can go to tchpconnect.org. That's tchpconnect.org. This is Melanie Cole. Thanks so much for listening.